Extra uterine GrowthNICU and Beyond

Dr. Salima Al Aisari

MD,DCH,OMSB,MRCPCH,

Neonatal Fellowship

Extra uterine growth retardation.

Historical Background.

Key competencies in Nutritional issues

Growth in NICU and beyond.

What is EUGR

EUGR is defined as measured growth

parameter( weight, length or head

circumference) that is less than or equal to

10th percentile of intrauterine growth

expectation based on estimated postmenstrual

age in premature (23-34) weeks estimated

gestational age neonates at the time of

hospital discharge.

Improving Child Nutrition

The achievable imperative for global progress

Millennium Developmental Goal

MDG 1 – Poverty & hunger

Higher risk of early growth retardation - stunting

Developmental delay (Feeding the developing

brain)

Developmental Origins of Health & Disease

“Fetal Programming”

Epigenetics is emerging as the hidden link between early life

exposure and late life events.

Under-nutrition during pregnancy & LBW are strongly associated with

HTN, obesity, insulin resistance and dyslipidemia later in life.

Goals of Nutrition

Weight gain

Neurodevelopment

Organ maturity and functioning

Prevention of infection

Development of immune function.

Warmth Infection control

Gavage Feeding

Early Feeding of Breast

Milk

Historical PERSPECTIVES Tarnier et Budin 1828-1907 at L’Hôpital Maternite at

in Paris Worked to develop the care of the “weakling

Snap from the past

Hess and Lundeen, 1941

Advocated delay of feedings.

“… too early feeding may be the cause of aspiration pneumonia…

small premature babies (<1200 g) are not fed for 24-48 hours…[but]

receive physiologic salt solution, subcutaneously in the thighs, one

to three times daily.”

An unfortunate legacy…….

Delayed feedings persisted for 25 years

Belief that such a practice prevented…

Aspiration pneumonia

Retention of excessive extracellular fluid, and

Subsequent stress on kidneys

Babies believed to be tough and able to tolerate

Hemoconcentration

Hyperosmolality

Hyperbilirubinemia

1960• Delayed feedings associated with long-term neurological

developmental delays

1960s

• (Kagan and Babson): Some weight gain with the use of cow’s milk formulas

1970s• (Raiha): Importance of protein “quality” not quantity

1980s

• Development of special formulas (increased protein, minerals, vitwith MCT for (VLBW) infants

1990s• Development of commercial human milk fortifiers

2000

• TPN becomes standard of care for VLBW

This century growth concern…..

Growth lags behind the “ in-utero”

counterpart.

Nutrient intakes are lower than in-

utero counterpart

Deficits may persist through

hospitalization and beyond

Do we practice What we Know

The incidence of EUGR in very-low-birth-weight infants ranges

between 43% and 97%

NUTRIQUAL Group in France studies 279 preterms in 29 different NICUs

and the authors documented:

There was divergence between the intended and the actual practice

for both Protein and Lipid intake.

Aggressive nutritional support of the very low birth weight preterm infant in the first week of

life is associated with improved initial and late growth

Rapid early growth is also linked to increased adiposity, which may cause later obesity,

increased blood pressure, and increased risk for cardiovascular disease

The Underlying Question…

“Do you want a smart, tall, fat adult who will die prematurely of

cardiovascular disease or a dumb, short, thin adult who will

outlive the other?”

Richard Schandler, MD Neonatalogist

Lapillonne et al. published “ Feeding Preterm Infants Today for

Later Metabolic and Cardiovascular Outcomes” in 2013,

reviewed the effects of fetal and postnatal growth, and early

nutrition on long-term cardiovascular and metabolic outcomes in

preterm infants.

Embleton et al. also studied Catch up growth and metabolic

outcomes in adolescents born preterm in 2016

Both documented early infancy nutrition in preterms doesn’t

affect metabolic status in adolescence.

No time to waste

Present evidence suggests that even brief periods of

relative under nutrition during a sensitive period of

development have significant adverse effects on later

development

Birth of LBW/preterm is a shock

Physiological stressors:

Temperature regulation

Breathing

Elimination

Separation

Stressor of prematurity & FEAR FACTOR

Ventilation

Apnea/seizures

UAC/UVC

Critical illness

Sepsis

More

“Hold feeds”

“Hold feeds”

“Hold feeds”

“Hold feeds”

“Hold feeds”

Factors independently associated with EUGR

Male Gender

Need for assisted

ventilation on day 1 of life.

History of NEC

Exposure to antenatal

steroids during the hospital

course.

EUGR

Prevention of Growth Restriction

Adapted from Adamkin DH. Feeding the Preterm Infant. In: Bhatia J, ed. Perinatal Nutrition:

Optimizing Infant Health and Development. New York, NY: Marcel Dekker; 2005:165–190

Unit Culture

Implementation of Evidence based Best-

practices

Doing right thing at right time in a right way

Principles of Early Nutrition Early total parenteral nutrition

Amino acids 3-3.5 g/kg/d

Lipids 1-2 g/kg/d

Carbohydrate (glucose)

Early and aggressive enteral feed

Colostrum swabbing

Early enteral feeding starting with 15-20ml/kg/day

Feeding protocols

Mother’s own milk

Donor human milk

Appropriate fortification

Typical Feeding ProgressionGestational Age (Weeks)

24 25 26 27 28 29 30 31 32 33 34 35 36 37 38

Pacifier Sucking (non-nutritive suck)

Gag Reflex

Rooting Reflex Early Intermediate Mature

Coordinate Suck,

Nutritive Suck Swallow, Breathe

TPN for 1-2 weeks as enteral Gradually start breast/ Infant nippling

feeds advance via tube bottle per infant cues all feeds

Enteral nutrition: when, what, and how much?

When to feed? Timing of feed

What to feed? Types of milk

How to feed? NGT/OGT/TP

How fast to feed? Increment of feed

Feeding in babies w/ BA/ Sepsis/ inotropes/

UAC/ Apnea/ PDA

BM plus HMF/Ca/Iron/MV

DHA/ probiotics

Enteral nutrition: when, what, and how much?

TPN versus enteral

EBM versus Formula

Early versus late

Slow versus aggressive

Population versus individuals

Critiques feel it is Impossible!

Significant stressors of extra uterine environment.

Associated disease states of ELBWs,

And… iatrogenic failure with current approach

Embleton NE et al. Postnatal malnutrition and growth

retardation: an inevitable consequence of current

recommendations in preterm infants?

Physical challenges to optimal nutrition

GI immaturities in the preterm infant include:

inability to coordinate breathing, sucking and swallowing

low esophageal sphincter pressure

delayed gastric emptying

slower upper and lower intestinal motility

immature digestion and absorption of carbohydrates, protein and lipids.

Preterm infants may therefore be at risk of acquiring abnormal bacterial

flora and developing nosocomial infections

RelationshipBetween

Patient/Client/Group & Dietetics

Professional

-

Nutrition Diagnosis

➢Identify and label problem➢Determine cause/contributing risk factors ➢Cluster signs and symptoms/ defining characteristics

Nutrition Assessment➢Obtain/collect timely and appropriate data➢Analyze/interpret with

evidence-based standards➢

➢ Identify risk factors➢ Use appropriate tools

and methods➢ Involve

interdisciplinary collaboration

Screening &

Referral System

Outcomes Management System

➢ Monitor the success of the Nutrition Care Process implementation

➢ Evaluate the impact with aggregate data➢ Identify and analyze causes of less than

optimal performance and outcomes➢ Refine the use of the Nutrition Care

Process

ADA NUTRITION CARE PROCESS AND MODEL

➢Document

Nutrition Monitoring and Evaluation➢ Monitor progress➢ Measure outcome indicators ➢ Evaluate outcomes➢ Document

Nutrition Intervention➢Plan nutrition intervention• Formulate goals and

determine a plan of action➢Implement the nutrition

intervention• Care is delivered and

actions are carried out➢Document

Document

Nutrition Beyond NICU

Approximately 30% of preterm infants remain below the 10th percentile for weight at 18 months, and about 20% at 7 to 8 years of age.

Key questions

Whether VLBW infants have special nutritional requirements in the post discharge period ?

Is post discharge nutrition also critical for later health and development?

Infants discharged with subnormal weight for CA should be supplemented or not ?

Post-Discharge Premature Infant Nutritional Issues

Switch from ‘super-milks’ to standard milk

Slower growth in follow-up

Limited information/research on post- discharge nutrition

Lack of proper follow up

Should we support post discharge fortification ?

1. One small trial found (n=39); provides some evidence that

multi nutrient fortification increases growth during infancy.

Further trials …

2. Two small trials of 246 infants; did not provide evidence that

multi nutrient fortification of breast milk for 3 or 4 months

after hospital discharge affected growth during infancy. One

trial did not find any statistically significant effects on

neurodevelopmental outcomes.

The Kaufman Assessment Battery for Children (K-ABC) Mental Processing Composite score (mean,

SD) at 5 years as a function of breastfeeding status at time of discharge and corrected age (*) at

which infants were weaned off breastfeeding, in EPIPAGE cohort. ‡p adjusted for propensity score.

Rozé JC, Darmaun D, Boquien CY, et al. The apparent breastfeeding paradox in very preterm infants: relationship between breast feeding,

early weight gain and neurodevelopment based on results from two cohorts, EPIPAGE and LIFT. BMJ Open. 2012;2(2):e000834

Thank you

Goals

Minimize time to regain birthweight

Suggested fluid, protein, and energy intakes

Fluid: 135-150 mL/kg/d

Protein: 3.5-4 g/kg/d (4-4.5 g/kg <1000 g)

Energy: 110-135 kcal/kg/d

Expected growth after return to birthweight

Weight: 15-20 g/kg/d

Length: 0.75-1.0 cm/week

Head circumference: 0.75-1.0 cm/week

Maintaining Breast Feeding

First 2-3 weeks

Use hand expression & compression w/ pumping

http://newborns.stanford.edu/Breastfeeding/MaxProduction.html

http://newborns.stanford.edu/Breastfeeding/HandExpression.html

Pump w/ double electric pump

Empty breasts at every pumping

Pump q 2-3 hrs/day & 1x/night (not to exceed 4 hrs)

Pump 7-10x/24 hours while establishing supply

After first 2-3 weeks (if adequate milk supply)

Pump q 4hr/day & 1x/night (not to exceed 5 hrs)

Pump 6-8x/24 hours

Normative Growth Data

Weight increases by 208gm/week from 28weeks gestation to 6 months.

Length increases by 1.1cm/week from 28weeks gestation to 40weeks

Head circumference increases by 0.75 cm/week during last trimester

Growth Indicators Stunting (inadequate length/height for age) captures

early chronic exposure to under nutrition.

Wasting (inadequate weight for height) captures acute

under nutrition.

Underweight (inadequate weight for age) is a composite

indicator that includes elements of stunting and

wasting.

Caloric Supplementation

Indications

1. Flat or decelerating growth curve pattern

2. Volume restricted (severe BPD, cardiac disease)

3. Unable to take enough

Monitor for dietary intolerance (GI symptoms, bloody

stools), hydration status

If increased caloric supplementation does not improve

growth further evaluation by endo., GI, dietitian